Drop Foot With Posterior Tibialis Weakness Treated With Peroneus Longus Transfer in a Child: A Case Report.

CASE: An 8-year-old girl with a history of acute flaccid paralysis presented with chronic valgus drop foot causing tripping and falling. Traditionally surgical correction of this deformity is accomplished by transferring the posterior tibialis tendon to enhance dorsiflexion. The authors describe a new technique which transfers the peroneus longus tendon to the dorsum of the foot in a patient with weakness of the posterior tibialis muscle. The patient's drop foot and gait were improved at the 22-month follow-up. CONCLUSION: Successful transfer of the peroneus longus was accomplished with improved limb clearance during gait and coronal alignment in stance.

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy.

BACKGROUND: Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures. PATIENTS AND METHODS: We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively. RESULTS: Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery. CONCLUSION: Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait. LEVEL OF EVIDENCE: Therapeutic level IV.

Update on the reliability of gait analysis interpretation in cerebral palsy: Inter-institution agreement.

BACKGROUND: Studies have shown good reliability for gait analysis interpretation among surgeons from the same institution. However, reliability among surgeons from different institutions remains to be determined. RESEARCH QUESTION: Is gait analysis interpretation by surgeons from different institutions as reliable as it is for surgeons from the same institution? METHODS: Gait analysis data for 67 patients with cerebral palsy (CP) were reviewed prospectively by two orthopedic surgeons from different institutions in the same state, each with > 10 years' experience interpreting gait analysis data. The surgeons identified gait problems and made treatment recommendations for each patient using a rating form. Percent agreement between raters was calculated for each problem and treatment, and compared to expected agreement based on chance using Cohen's kappa. RESULTS: For problem identification, the greatest agreement was seen for equinus (85% agreement), calcaneus (88%), in-toeing (89%), and out-toeing (90%). Agreement for the remaining problems ranged between 66-78%. Percent agreement was significantly higher than expected due to chance for all issues (p ≤ 0.01) with modest kappa values ranging from 0.12 to 0.51. Agreement between surgeons for treatment recommendations was highest for triceps surae lengthening (89% agreement), tibial derotation osteotomy (90%), and foot osteotomy (87%). Agreement for the remaining treatments ranged between 72-78%. Percent agreement for all treatments was significantly higher than the expected values (p ≤ 0.002) with modest kappa values ranging from 0.22 to 0.52. SIGNIFICANCE: Previous research established that computerized gait analysis data interpretation is reliable for surgeons within a single institution. The current study demonstrates that gait analysis interpretation can also be reliable among surgeons from different institutions. Future research should examine reliability among physicians from more institutions to confirm these results.

Influence of the percutaneous myofasciotomy on gait of children with spastic cerebral palsy - A short term, retrospective controlled analysis.

BACKGROUND: One of the primary causes in children with cerebral palsy (CP) leading to gait disorders is an increased muscle tone which may secondary result in a shortening of the muscle fascia. Percutaneous myofasciotomy (pMF) is a minimal-invasive surgical intervention correcting the shortened muscle fascia and aims to extend the range of motion. RESEARCH QUESTION: What is the effect of pMF on gait in children with CP three months and one year post-OP? METHODS: Thirty-seven children (f: n = 17, m: n = 20; age: 9,1 ± 3,9 years) with spastic CP (GMFCS: I-III, bilateral (BSCP): n = 24, unilateral (USCP): n = 13) were retrospectively included. All children underwent a three dimensional gait analysis with the Plug-in-Gait-Model before (T0) and three months after pMF (T1). Twenty-eight children (bilateral: n = 19, unilateral: n = 9) underwent a one-year follow-up-measurement (T2). Differences in the Gait Profile Score (GPS), kinematic gait data, gait-related functions and mobility in daily living were statistically analyzed. Results were compared to a control group (CG) matched in age (9,5 ± 3,5 years), diagnosis (BSCP: n = 17; USCP: n = 8) and GMFCS-level (GMFCS I-III). This group was not treated with pMF but underwent two gait analyses in twelve months. RESULTS: The GPS improved significantly in BSCP-pMF (16,46 ± 3,71° to 13,37 ± 3,19°; p < .0001) and USCP-pMF (13,24 ± 3,27° to 10,16 ± 2,06°; p = .003) from T0 to T1 with no significant difference between T1 and T2 in both groups. In CG there was no difference in the GPS between the two analyses. SIGNIFICANCE: PMF may in some children with spastic CP improve gait function three months as well as for one-year post-OP. Medium and long-term effects, however, remain unknown and further studies are needed.

Persistent increase in anterior pelvic tilt after hamstring lengthening in children with cerebral palsy.

BACKGROUND: Hamstring lengthening has traditionally been the surgical treatment of choice to correct flexed knee gait in children with cerebral palsy (CP). Improved passive knee extension and knee extension during gait are reported post hamstring lengthening, but concurrent increased anterior pelvic tilt also occurs. RESEARCH QUESTION: Does anterior pelvic tilt increase after hamstring lengthening in children with CP both in the short-term and mid-term, and what predicts increased post-operative anterior pelvic tilt? METHODS: 44 participants were included (age 7.2, SD 2.0 years; 5 GMFCS I, 17 GMFCS II, 21 GMFCS III, 1 GMFCS IV). Mean pelvic tilt was compared between visits, and the effect of potential predictors of change in pelvic tilt was examined using linear mixed models. The relationship of change in pelvic tilt to change in other variables was examined using Pearson correlation. RESULTS: Anterior pelvic tilt increased significantly post-operatively by 4.8° (p < 0.001). It remained significantly higher by 3.8° at 2-15 years follow-up (p < 0.001). Change in pelvic tilt was not affected by sex, age at surgery, GMFCS level, assistance during walking, time since surgery, or baseline values of hip extensor strength, knee extensor strength, knee flexor strength, popliteal angle, hip flexion contracture, step length, walking speed, maximum hip power in stance, or minimum knee flexion in stance. Pre-operative dynamic hamstring length was associated with greater anterior pelvic tilt at all visits but did not affect amount of change in pelvic tilt. Patients in GMFCS I-II showed a similar pattern of change in pelvic tilt to GMFCS III-IV. SIGNFICANCE: When considering hamstring lengthening for ambulatory children with CP, surgeons should weigh increased mid-term anterior pelvic tilt post-operatively with the desired outcome of improved knee extension in stance. Patients with neutral or posterior pelvic tilt and short dynamic hamstring lengths pre-operatively have lowest risk of excessive post-operative anterior pelvic tilt.

Rectus femoris surgery for the correction of stiff knee gait in cerebral palsy: A systematic review and meta-analysis.

INTRODUCTION: Rectus femoris (RF) transfer was long the gold-standard treatment for stiff knee gait (SKG), but efficacy now seems less than that of distal RF release. The aim of the present study was to compare efficacy between the two. The study hypothesis was that both significantly improve 4 knee kinematic parameters at 1 year. PATIENTS AND METHOD: A meta-analysis was performed, using PRISMA criteria, on the Medline, Science Direct, Cochrane Registry, Scopus and Pascal databases. Search was conducted up to March 1, 2020 by two authors (A.J & M.T). Study methodology was assessed on MINORS index. Inclusion criteria comprised patients with SKG, treated by RF transfer or distal release. Endpoints comprised: Peak Knee Flexion in swing phase (PKFSW), Knee Range of Motion (KROM), time to Peak Knee Flexion (t-PKFGC), and Maximum Knee Extension in stance phase (MKEST). Effect size was assessed on Standard Mean Deviation (SMD). RESULTS: A total of 695 studies were identified, 16 of which were included: 14 transfer, 5 release. Data were analyzed for 1,079 limbs in 768 patients. Only transfer improved PKFSW, with small effect size (SMD=0.29). The other three parameters were improved by both techniques, with moderate effect size. DISCUSSION: Results showed improved knee kinematics after RF transfer, but with small or moderate effect size. The effect of distal release on PKF could not be assessed, due to publication bias. The heterogeneity of studies and low levels of evidence call for caution in interpreting the present results. LEVEL OF EVIDENCE: III.

Rectus femoris transfers with and without a hamstring lengthening will not change hip kinematics in children with cerebral palsy.

BACKGROUND: A rectus femoris transfer (RFT) surgery with and without a hamstring lengthening (HSL) is used to treat stiff-knee gait in children with cerebral palsy (CP). While current literature has reported that a RFT surgery improves the kinematics at the knee, little is known about the kinematic changes at the hip. RESEARCH QUESTION: Does a RFT surgery change hip joint kinematics in children with CP? METHODS: This retrospective study included children (<18 years old) diagnosed with CP, who underwent a RFT procedure, and who were seen at our institution's accredited clinical motion laboratory. Patients with both pre- and post-operative gait analysis were identified and comparison between those analyses were performed to identify kinematic differences at the hip and knee. A total of 66 legs from 46 children (mean age: 11.1 ± 3.6) met the inclusion criteria. RESULTS: Overall results revealed that a RFT did not change kinematics at the hip [p > 0.05], however, a RFT did increase the maximum knee flexion during the swing period [Mean Difference Post - Pre: 8.3°, 95% CI: 4.9-11.8, p < 0.0001]. Additionally, it was found that changes in hip extension during the terminal stance phase were significantly different between the combined RFT and HSL compared to solely an RFT. The results of this study also revealed that children whose stiff-knee gait did not improve, tended to have increased hip external rotation during terminal stance and swing and greater hip extension during terminal stance, compared to children whose stiff-knee gait did improve. SIGNIFICANCE: Overall, a RFT with and without a HSL surgery improves hip and knee kinematics in the sagittal plane, however, improvements at the hip were not clinically significant. As a result, a RFT or a combined RFT with HSL should not be used to change hip kinematics in children with CP.

Quantitative gait analysis value as a predictor of shunt surgery effectiveness in normal pressure hydrocephalus: A technical note.

INTRODUCTION: Shunt surgery (SS) remains the most effective treatment for idiopathic Normal pressure hydrocephalus (iNPH), but the selection of the patients with the greatest potential benefit remains elusive. OBJECTIVE: Identify gait features predictive of best response to SS in iNPH. METHODS: Eight patients with iNPH were assessed at baseline, after Cerebrospinal fluid tap-test (CSF-TT) and SS, with clinical scales (Clinical/Patient Global Clinical Impression, EuroQol-5D, Clinical Dementia Rating Scale(CDR), MoCA test, Hoehn-Yahr Scale) and gait analysis with inertial sensors. RESULTS: The 8 included iNPH patients had a mean age of 73 years(59-81), moderate cognitive (CDR-1.5 (0.5-2); MoCA-9.5 (3-21)) and motor impairment (Hoehn-Yahr-2.75(2-3)). After SS, patients had a significant improvement in cognition (MoCA, p = 0.001) and quality of life. At baseline, patients with lower improvement (no change/ minimally improved) (n = 2), in comparison to patient with higher improvement (much/very much improved) (n = 6), already had higher cognitive impairment (MoCa-3(3-3) vs. 11(7-21)). Patients with lower improvement had a lower % of change in gait performance at LP (mean 10.2 %) and were absent of additional benefit after SS(mean -0.8 %). In contrast, gait performance in patients with higher improvement consistently got better from baseline to LP (mean 23.1 %) and from baseline to SS (mean 82.9 %). A significant negative correlation was observed between CDR score and several gait variables: speed (rpb=-0.92,p = 0.009); stride length (rpb=-0.92,p = 0.009); lift-off angle (rpb=-0.96,p = 0.003); and maximum heel (rpb=-0.81,p = 0.049). CONCLUSION: The magnitude of gait improvement after CSF-TT, quantified by gait analysis, can be used as an integral variable in the multimodal clinical approach to the prediction of improvement after SS.

Assessment of gait quality and efficiency after undergoing a single-event multilevel surgery in children with cerebral palsy presenting an intoeing gait pattern.

PURPOSE: The biomechanical impact of undergoing a single-event multilevel surgery (SEMLS) for children with cerebral palsy (CP) presenting an intoeing gait pattern has been widely documented. However, past studies mostly focused on gait quality rather than efficiency. Thus, there is a need to determine the impact of undergoing a SEMLS on gait quality and efficiency in children with CP presenting an intoeing gait pattern. METHODS: Data from 16 children with CP presenting an intoeing gait pattern who underwent a SEMLS were retrospectively selected. Gait kinematics was quantified before (baseline) and at least 1 year after the surgery (follow-up). Gait quality was investigated with the Gait Profile Score (GPS), hip internal rotation angle and foot progression angle (FPA). Gait efficiency was analysed using clinically accessible variables, namely the normalised gait speed and medio-lateral and vertical centre of mass excursions (COMp). Dependent variables were compared between sessions with paired t-tests. RESULTS: At the follow-up, children with CP exhibited a more outward FPA and GPS as well as a decreased hip internal rotation angle. No changes in normalised gait speed and vertical COMp excursion were observed, and medio-lateral COMp excursion was slightly decreased. CONCLUSION: Children with CP presenting an intoeing gait pattern who underwent a SEMLS exhibited an increased gait quality, but gait efficiency was only minimally improved at the follow-up compared to baseline. Further studies are needed to identify contributors of gait efficiency in children with CP, and the best treatment modalities to optimise both their gait quality and efficiency.

Cost savings for single event multilevel surgery in comparison to sequential surgery in ambulatory children with cerebral palsy.

BACKGROUND: The purpose of this study was to determine the differences in billable provider charges between single event multilevel surgery (SEMLS) based on comprehensive gait analysis and a staged surgical approach (SSA) without comprehensive gait analysis for the orthopedic treatment of ambulatory children with cerebral palsy (CP). METHODS: The charges associated with nine common orthopedic surgical combinations (both unilateral and bilateral, soft tissue or soft tissue plus bony) for children with CP were determined and compared between SEMLS and SSA. The charges included surgical, anesthesia, operating room, recovery room, hospital stay, physical therapy, and, for SEMLS only, comprehensive computerized gait analysis. RESULTS: Total charges to complete each combination was higher for SSA than for SEMLS. The differential ranged from $10,247 to $75,069 with the percentage difference ranging from 20% to 47%. The mean difference was $43,606 (p = 0.0002). The dollar difference (r = 0.98, p < 0.0001) and percentage difference (r = 0.79, p = 0.01) were both related to the total charge of the SEMLS surgery. SIGNIFICANCE: Financial costs are lower for SEMLS vs. SSA for the treatment of multilevel gait issues in children with CP. The cost of gait analysis is much smaller than the cost differential between SEMLS and SSA. Although some patients who have SEMLS may need additional orthopedic surgery with associated costs, this is also possible for SSA. Therefore, due to the many benefits of SEMLS, which also include more informed treatment decision-making as well as reduced time away from school and work (for caregivers), SEMLS guided by gait analysis is recommended over SSA for the treatment of gait disorders in children with CP.

Long-term follow-up after multilevel surgery in cerebral palsy.

INTRODUCTION: Single-event multilevel surgery (SEMLS) is frequently used to correct pathological gait patterns in children with bilateral spastic cerebral palsy (BSCP) in a single session surgery. However, in-depth long-term evaluation reports of gait outcomes are limited. Therefore, we investigated if SEMLS is able to correct lower extremity joint and pelvic angles during gait towards typically developing gait patterns (TDC) in children with BSCP, and if so, if this effect is durable over a 10-year period. MATERIALS AND METHODS: In total 13 children with BSCP GMFCS level II at time of index-surgery between the ages of 7.7-18.2 years at the time of SEMLS were retrospectively recruited. Three-dimensional gait data were captured preoperatively, as well as at short-, mid-, and long-term post-operatively, and used to analyze: movement analysis profile (MAP), gait profile score (GPS), and lower extremity joint and pelvic angles over the course of a gait cycle using statistical parametric mapping. RESULTS: In agreement with previous studies, MAP and GPS improved towards TDCs after surgery, as did knee extension during the stance phase (ɳ2 = 0.67; p < 0.001), while knee flexion in the swing phase (ɳ2 = 0.67; p < 0.001) and pelvic tilt over the complete gait cycle (ɳ2 = 0.36; p < 0.001) deteriorated; no differences were observed between follow-ups. However, further surgical interventions were required in 8 out of 13 of the participants to maintain improvements 10 years post-surgery. CONCLUSIONS: While the overall gait pattern improved, our results showed specific aspects of the gait cycle actually deteriorated post-SEMLS and that a majority of the participants needed additional surgery, supporting previous statements for the use of multilevel surgery rather than SEMLS. The results highlight that the field should not only focus on the overall gait scores when evaluating treatment outcomes but should offer additional long-term follow-up of lower extremity function.

Perceived and actual changes in gait balance after CSF shunting in idiopathic normal pressure hydrocephalus.

OBJECTIVES: We evaluated the perceived and actual changes in gait and balance function immediately after cerebrospinal fluid (CSF) shunting in patients with idiopathic normal pressure hydrocephalus (iNPH), including those with mild cases. MATERIALS AND METHODS: Ninety-nine iNPH patients were assessed using the timed Up and Go (TUG) and Functional Gait Assessment (FGA) before and 1-week after CSF shunting and their perceived changes were assessed on a Global Rate of Change (GRC) scale. Minimal clinically important differences (MCIDs) were calculated using a receiver operating characteristic (ROC) curve method using GRC scores. RESULTS: In all patients (n = 99), the TUG value postoperatively was significantly faster than the preoperative value (difference; 3.1 ± 4.6 s, p < 0.001), and the postoperative FGA score was significantly better than the preoperative score (difference; 3.8 ± 3.3 points, p < 0.001). In the TUG <15 s group (n = 51), the postoperative FGA score was significantly improved (difference; 3.3 ± 2.9 points, p < 0.001), whereas the TUG value was only slightly improved (difference; 0.6 ± 1.6 s, p = 0.008). The ROC curve MCIDs of GRC ≥2 points, which is the recommended level of improvement, were 1.7 s (16.5%) for the TUG and 4 points (20.0%) for the FGA in all patients (n = 99) and the TUG <15 s group (n = 51). CONCLUSIONS: FGA can be used to confirm treatment effects, including perceived and actual changes after CSF shunting, in patients with mild iNPH. Our results can help clinicians to determine the clinical significance of improvements in gait and balance function immediately after CSF shunting in individual patients with iNPH.

Outcomes of Patellar Tendon Imbrication With Distal Femoral Extension Osteotomy for Treatment of Crouch Gait.

BACKGROUND: Crouch gait is a frequent gait abnormality observed in children with cerebral palsy. Distal femoral extension osteotomy (DFEO) with the tightening of the extensor mechanism is a common treatment strategy to address the pathologic knee flexion contracture and patella alta. The goal of this study was to review the results of a patellar tendon imbrication (PTI) strategy to address quadriceps insufficiency in the setting of children undergoing DFEO. METHODS: After institutional review board approval, all patients with crouch gait treated at a single institution with DFEO and PTI were identified. Clinical, radiographic, and instrumented gait analysis data were analyzed preoperatively and at 1 year following surgery. RESULTS: Twenty-eight patients (54 extremities) with a diagnosis of cerebral palsy and crouch gait were included. Significant improvements were appreciated in the degree of knee flexion contracture, quadriceps strength, knee extensor lag, and popliteal angle (P<0.01). Knee flexion at initial contact and during mid-stance improved significantly (P<0.0001), and knee moments in late stance were significantly reduced (P<0.01). The anterior pelvic tilt, however, significantly increased postoperatively (P<0.0001). Radiographic improvements were seen in the knee flexion angle and patellar station as assessed by the Koshino Sugimoto Index (P<0.0001). Four patients (14.2%) developed a recurrence of knee flexion contracture requiring further intervention. CONCLUSIONS: PTI is a simplified and safe technique to address quadriceps insufficiency when performing DFEO. The short-term results of patients who underwent DFEO with PTI demonstrated improvements in clinical, radiographic, and gait analysis variables of the knee. Investigating long-term outcomes, comparing techniques, and assessing quality of life measures are important next steps in research. LEVEL OF EVIDENCE: Level IV-case series.

Surgical Outcomes for Severe Idiopathic Toe Walkers.

BACKGROUND: Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed. METHODS: After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery. RESULTS: Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings. CONCLUSIONS: Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings. LEVEL OF EVIDENCE: Level III-case series.

Evaluation and Treatment of Foot Drop Using Nerve Transfer Techniques.

Foot drop represents a complex pathologic condition, requiring a multidisciplinary approach for appropriate evaluation and treatment. Multiple etiologic factors require recognition before considering invasive/operative intervention. When considering surgical management for the treatment of foot drop, it is first and foremost imperative to establish the cause of the condition. Not all causes resulting in clinical foot drop have surgical options. Establishing a cause allows the provider to more appropriately curtail a multidisciplinary approach to working-up, and ultimately, treating the patient. The authors offer an algorithm for evaluating and treating foot drop conditions associated with lumbar spine radiculopathy and peripheral nerve lesions.

A comprehensive clinico-radiological, neuropsychological and biomechanical analysis approach to patients with idiopathic normal pressure hydrocephalus.

BACKGROUND: A systematic approach to patients with suspected idiopathic normal pressure hydrocephalus (iNPH) is essential to recognize the subset of patients who may benefit from ventriculoperitoneal shunt surgery (VPS). Quantitative biomechanical analysis of gait and balance (QBAGB) may help objectify the response to the cerebrospinal fluid tap test (CSF-TT) and VPS outcome after 3 months and support identification of candidates for VPS. METHODS: We retrospectively reviewed data from all patients with probable iNPH who 1) underwent clinico-radiological and neuropsychological assessments using validated scales (iNPH Scale and iNPH Radscale) at our centre in the period from January to December 2018; and 2) had completed QBAGB before CSF-TT ('baseline'), shortly after CSF-TT, and at three months after either VPS or conservative treatment. RESULTS: At the time-points 'after CSF-TT' and '3 months', patients with iNPH and VPS (n = 11) significantly improved on the Kiefer Scale score, iNPH Scale total score and gait domain score, as well as in gait velocity and step length measured by QBAGB. In contrast, patients without surgery (n = 10) had unchanged iNPH Scale scores and motor performance throughout. Using data from all patients, we calculated cut-off levels for substantial improvements in gait velocity, step length, and the iNPH Scale domain gait score at the time-point 'after CSF-TT'. CONCLUSION: QBAGB helps to objectify the response to CSF-TT to select candidates for VPS and corroborates clinico-radiological and neuropsychological data derived from validated scales. The QBAGB cut-off values for substantial improvement after CSF-TT need further elucidation in larger, preferably prospective studies.

A comparison of conventional and minimally invasive multilevel surgery for children with diplegic cerebral palsy.

AIMS: To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). METHODS: A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded. RESULTS: In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively. CONCLUSION: This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192-197.

Role of DESH, callosal angle and cingulate sulcus sign in prediction of gait responsiveness after shunting in iNPH patients.

Primary endpoint of this single-centre, prospective consecutive cohort study was to evaluate DESH score, CA, CSS and Evans index of suspected iNPH patients against the reference standard of lumbar infusion test (LIT) and external lumbar drainage (ELD) in prediction of gait response after VP shunt implantation in patients with idiopathic normal pressure hydrocephalus (iNPH). Patients were assigned to NPH and non-NPH groups based on LIT and ELD results. Age-matched controls were added for group comparison. 32 NPH, 46 non-NPH and 15 control subjects were enrolled in the study. There were significant differences in mean preoperative DESH scores of NPH, non-NPH and control groups (6.3 ± 2.3 ([±SD]) (range 2-10) vs 4.5 ± 2.4 (range 0-10) vs 1.0 ± 1.2 (range 0-4)). Differences in mean CA and Evans index were not significant between NPH and non-NPH groups. CSS showed 62.5% sensitivity, 60.87% specificity, 52.63% PPV and 70% NPV for differentiation of NPH and non-NPH groups. A CA of 68 degrees had 48.49% sensitivity, 76.09% specificity, 59.26% PPV 67.31% NPV and DESH score of 4 had 93.75% sensitivity, 41.30% specificity, 52.63% PPV and 90.48% NPV for differentiation between NPH and non-NPH groups. The groups of probable iNPH patients with gait impairment diagnosed by high DESH score or positive functional testing did not overlap and DESH score did not correlate with gait improvement after ELD. DESH score should not be used as a simple diagnostic or prognostic marker of iNPH and we could not confirm the benefit of measurement of callosal angle and cingulate sulcus sign.

Utilization of Intraoperative Biphasic Waveform Nerve Stimulator for Performing Nerve Transfer for the Treatment of Drop Foot: Addendum to Evaluation and Treatment of Foot Drop Using Nerve Transfer Techniques.

This article provides the surgeon with a detailed technique guide using an alternating current biphasic waveform intraoperative nerve stimulator, such as the Checkpoint surgical nerve stimulator. The Checkpoint surgical nerve stimulator is an intraoperative hand-held biphasic device that is essential when performing nerve transfer techniques for the treatment of drop foot. This specific device provides the surgeon safe, accurate, reproducible, and continuous stimulation without fatigue or a decreased response to the nerve. An in-depth technique guide is provided while using this device while performing a nerve transfer for the treatment of drop foot.

Rectus femoris transfer in children with cerebral palsy: comparing a propensity score-matched observational study to a randomized controlled trial.

AIM: To test whether an observational study employing propensity score matching could accurately estimate the causal treatment effects of rectus femoris transfer (RFT) as part of single-event multilevel surgery (SEMLS) in ambulatory children with cerebral palsy. METHOD: We used a large clinical database to derive a propensity score for treatment assignment (SEMLS±RFT) and used this score to generate a matched patient cohort. We compared the causal treatment effects estimated from this matched cohort with a previously published randomized controlled trial (RCT). RESULTS: The treated arms of the observational study and RCT were well matched. There were 129 limbs (81 males) with a mean age of 10 years 7 months (4y 7mo) in the treated arm of the observational study, and 129 limbs (68 males) with a mean age of 10 years 2 months (3y 9mo) in the control arm of the observational study. Differences between the observational study and RCT cohorts were clinically meaningless for knee flexion kinematics (1-4°), timing of knee angle extrema (<3% gait cycle), and speed (<5mm/s). Postoperative changes in the observational study matched those from the RCT. All but one of the observational study confidence intervals were completely contained within the corresponding RCT confidence interval; there were no meaningful differences in magnitude or sign of key outcomes related to stiff knee gait. INTERPRETATION: Propensity score matching is an accurate method for estimating the causal treatment effects of RFT as part of an SEMLS. It seems reasonable to extend this approach to other common components of SEMLS treatment in this population. WHAT THIS PAPER ADDS: Propensity score matching is an accurate method for estimating the causal treatment effects of rectus femoris transfer (RFT) in ambulatory children with cerebral palsy (CP). The causal treatment effects for RFT surgery in ambulatory children diagnosed with CP were validated.